Case Study: Stroke Rehabilitation - Assessment and Upper Limb Intervention

Updated: Jul 4, 2019

By Jamie Grant - Director, The Occupational Therapy Hub.

Originally written in 2016.


I first met 'Mr. M' on a stroke ward, when I assisted another occupational therapist with the patient’s self care (wet shaving). On discharge to the stroke discharge team, I led and co-facilitated Mr. M’s upper limb assessments, with regular visits to his home. I was then able to lead a home exercise programme (HEP) and shaving intervention, both of which were meaningful to him and focused on key skill deficits following his stroke. His rehabilitation was also supported by a nurse and support workers.



Background


DIAGNOSIS: Ischaemic stroke in left cerebral hemisphere; right side affected


DOMINANT HAND: Left hand

PAST MEDICAL HISTORY: Ex smoker


HOME ENVIRONMENT: 2-storey house; 1 flight of stairs; upstairs bathroom.


SOCIAL ENVIRONMENT: Lives with his mother, whom he cares for. She is a heavy smoker and had a past stroke herself. He does most of the housework and cooking for them both.


Upper limb assessments


The following assessments were carried out with Mr. M:

  • Neurological assessment

  • Upper limb assessment

  • 9-hole peg test


Through this broad approach, therapists were able to establish the patient’s ability in the following domains:

  • Range of movement (ROM)

  • Muscle strength and tone

  • Dexterity

  • Proprioception

  • Coordination

  • Sensory awareness


Initial presenting symptoms and ability level


Right-sided muscle weakness:

  • Main deficit in U/L fine motor strength, dexterity and range of movement (ROM). Good gross ROM

  • L/L largely unaffected, with minor foot drag. Mobilising independently around the flat, no balance issues

Moderate sensory deficit in right U/L

Proprioception and coordination impairment – reduced ability to mirror affected U/L position with eyes shut

Mild receptive and expressive dysphasia

Mild dysarthria


Home adaptations – none made, due to Mr. M’s sufficient mobility and strength.


Client-centred goals


Following the outlined assessments, key motor and sensory-related goals were set, through discussion, input and mutual agreement with the service user:

  • To regain sensation in right U/L

  • To improve right hand dexterity, coordination and proprioception

  • To improve right shoulder flexion, increasing active ROM

  • To improve right wrist extension, increasing active ROM

Mr. M wanted to get back to meaningful occupations he participated in before his stroke. Those most important to him were:

  • ADLs: Wet shaving; using cutlery for meals

  • Leisure: bowling/skittles at his local club

  • Productivity: Supportive tasks as a carer to his mother


Interventions – encompassing clinical reasoning and problem solving


Interventions were established with Mr. M that would improve his motor and sensory ability and enable him to continue with the meaningful occupations listed above. Highlighted below are some of these interventions:


Wet shaving

Mr. M stated that shaving was a key priority for him, given that he would be going out in the community again this week. He needed guidance to build up confidence with everyday tasks such as this. Initially, I planned to get him to practise brushing his Bic razors against his stubble, but with the blade guards on. This would allow him to work on the upper limb movements and pressure level required with the razor, without cutting his skin. However, given that he had right-sided weakness but his left hand is dominant, I reasoned that, with caution, he could start shaving straightaway without the blade guards.


Mr. M was able to shave to a level he was satisfied with. He applied shaving foam and used the razor correctly. He was supported by sufficient strength and dexterity of his unaffected left hand, alongside improved sensation on the right side of his face.


Barriers included navigating around a post-surgery scar on his neck and wearing the wrong glasses at one point. I perceived that he could have cut hairs a little shorter. However, Mr. M stated that this was the first time shaving since his return from hospital and he would try again in the coming days.


Home Exercise Programme [HEP]

Exercises were compiled into a HEP. The programme focused on dexterity and balance, for his ADLs and leisure interest of bowling, respectively.



Impact of patient’s role: carer for mother


During Mr. M’s session with myself and his occupational therapist, it became clear that the combination of his stroke recovery and the caring responsibilities for his mother were impacting on his mood. Mr. M was observed losing his temper with his mother. He later mentioned to me how she was recently impatient with him when he was making her a hot drink. He stated that she has been used to his support until now and that this currently puts a strain on him, given his own need for rehabilitation.


In terms of finding a solution, I asked Mr. M if he had any friends or other family locally, who could occasionally support his mother instead. This would provide some respite for him. Additionally, I suggested that he take more time out of the house, to participate in bowling, go shopping or take a walk, given his good lower limb mobility. He was not overly forthcoming in his response to these ideas, but acknowledged they might help.

Mr. M is still continuing occupational therapy rehabilitation and I will be visiting him in the coming weeks. Respite, such as that discussed above, should be reviewed before he is discharged from the stroke discharge service.


Personal practice reflection


I have enjoyed being part of Mr. M’s rehabilitation so far, especially given his very occupational therapy-centred interventions of shaving and upcoming return to bowling. Professionally, I believe my confidence has developed when physically assessing motor function of the upper limb and during the rest of his neurological assessment. This has included examining the extent of his field of vision. I have needed to carefully problem solve, when putting together a relevant exercise programme to match his deficits. It is clear that he has been engaging with his HEP. I look to continue working on his proprioception and developing his U/L sensory ability in the coming week.



Originally written in 2016.

Setting: A stroke discharge service in the UK.

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